Monday, 29 December 2014

Despite the fact that I've written a handful of complimentary posts about myself, I'm not one to toot my own horn very often. That said, though I rarely claim to be smarter than anyone, I have to admit that I'm a fairly intelligent guy. Despite this, I've written about things I don't understand in the past, and it's been quite a while since I have, so I feel it's high time I embiggen the list of things I just can't seem to wrap my mind around.

women (yes, I still don't understand them)

the appeal of mushrooms

how anything got done before the Internet

Twilight

smoking

Of the myriad things I just can't fathom, I think I understand smoking the least. With all of the health problems that cigarettes cause, I simply can't understand how anyone these days could possibly begin (or continue) smoking. Now before anyone starts yelling and screaming that nicotine is addictive, I ALREADY KNOW. I know how easy it is to become addicted to cigarettes, and I know how difficult it is to quit once you're hooked. But it's a rare soul who doesn't know at least one person who was affected adversely by cigarettes - lung cancer, emphysema, chronic bronchitis, oral cancer, cataracts, heart disease, stroke . . .

About a month prior to coming to my hospital, Samuel's aorta, that rather-important artery that comes off the heart and supplies blood to the entire body, had become completely blocked at the point where it splits to supply blood to the legs, so a bypass surgery was done at an outside hospital.

Today Samuel was having severe abdominal pain, so the emergency physician correctly presumed that he was having a complication from that surgery. He promptly ordered a CT scan of his abdomen which fortunately ruled out any complication of his bypass (such as a leak or infection or blockage of an artery), but it surprisingly showed a small bowel obstruction. His small intestine was dilated to about 8-times its normal diameter, but more even more ominous was that it looked like the blood supply to a segment of the bowel had twisted on itself, an entity called intestinal volvulus. Any tissue whose blood supply is twisted will eventually die, so this is a dire surgical emergency.

Thirty minutes later he was in the operating theatre, and 30 minutes after that I had successfully untwisted his intestine, which was perhaps an hour or so from dying. As you can probably imagine, that's not a good thing. I watched it for a few minutes, waiting for the colour to normalise (it did), and then I closed him up. Another life saved!

Maybe. (Cue the dramatic music.)

I went out to the waiting room to find his wife and let her know that everything went well. As I was chatting with her and letting her know how I expected his recovery to go, a familiar odour reached my nostrils - cigarette smoke. After I was done, I asked her if she had any questions. When she said "no", I told her that I had one:

"When are you going to quit smoking?"

Her smile immediately faded, and she looked at her feet. "We're trying to quit," she almost whispered.

Wait . . . we? Are you telling me this man who nearly lost his legs a month ago because of his smoking is STILL SMOKING?

With a stern look and not even a hint of mirth, I told her that she and Samuel had to quit. NOW. "I don't care if you go cold turkey, use nicotine gum, a nicotine patch, prescription medicine, chewing gum, e-cigarettes, meditation, yoga, hypnosis, acupuncture, or voodoo," I said, trying not to yell. "Your smoking was making him smoke, and his smoking is killing him, slowly but surely."

I sent Samuel home a week later, repeatedly beating my point into his skull daily. Unfortunately (though perhaps not surprisingly) he never showed up for his follow-up appointment.

I don't expect perfection, except from myself (though I rarely attain such heights). But I do expect people to help me help them get better. Why can't (or won't) so many people do that?

Tuesday, 16 December 2014

WARNING: I WILL BE SHAMELESSLY RISKING SPRAINING MY SHOULDER BY PATTING MYSELF ON THE BACK IN THIS POST.
Admittedly this blog is dedicated to idiots and stupidity, and as I've said numerous times my favourite idiot remains me. So having told several stories where I am the goat, I think I've disparaged myself enough to have earned myself a complimentary update.

If you want more idiot stories, you'll have to wait. Probably not very long.

Since finishing my training I have spent very little time around other doctors in clinical situations, so I therefore have no idea how my colleagues speak to patients. I don't know what kind of terminology they use, if they have prepared speeches for certain situations, or how they treat patients in general. I have a fairly well-established bedside manner, and it seems to serve me very well in the vast majority of situations. Though my demeanor rarely changes much, every now and then I have to tailor it for certain types of patient (those who are very difficult, very drunk, very upset, very young, very old, etc). Some people need a bit more care, some need a stern talking-to, others need massive doses of sedatives to shut them up.

Kidding, kidding. Sort of.

Generally speaking, my philosophy is this: If you're nice to me, I'll be nice to you. Because of this ideology, every so often patients tell me (compliment warning) that I make them feel better just by sitting with them for a few minutes, talking with them, and explaining everything in excruciating detail, probably more detail than they want or need.

When he was brought to me about 30 minutes later, he was clearly agitated, clutching his chest and having trouble breathing. When I pushed lightly on his chest, he grunted and looked at me as if I were Satan. His chest felt unstable to me, and an X-ray confirmed that he had 4 fractured ribs. Fortunately his lung had not collapsed, he had no bleeding in his chest, and he had no other serious injuries. I explained that his injuries were painful but not life-threatening and that the only treatment was pain medicine and time. That seemed to calm him somewhat.

Over the next several days, I quickly assessed that he would be a patient who required a bit more TLC than my typical patients. My daily rounds with him, which should have taken no more than 3 minutes to press on and listen to his chest, assess his pain, and go over his X-ray, took at least 15 minutes while I sat with him, listened to him describe his pain, and reassured him that he would heal, but it would simply take time.

A few days later his pain had improved to the point where he could walk without difficulty, and he no longer needed IV narcotics. I discharged him, telling him he could continue his recovery at home, though it would be several more weeks until he felt completely better.

As I was sitting in my office about a week later, I got a call from Nathaniel, asking if he could transfer his care to me. Confused, I told him I was already his doctor, so I asked him what he meant. "Well, I really liked the way you cared for me in the hospital. You were so patient with me and you really listened to me, so I want you to be my primary doctor."

I told him that while I don't do primary care, I was truly honoured by the request, and that simple question was one of the best compliments a surgeon could get. I gave him the phone number for an internist whose philosophy is very similar to mine - be direct and honest, and above all else listen to the patient.

To the medical students reading this, I hope you take this vignette to heart and learn a valuable lesson that DadBastard and GrandpaBastard taught me a long time ago. Ultimately all patients want the same thing: to be treated like a human being. What I did isn't difficult, it isn't special, and it isn't unique.

Monday, 8 December 2014

That's a phrase that enters my brain almost every time I am on call. After seeing children shot in the head, grown men crying like babies over minor abrasions, a woman kicked in the head by a deer, a man impaled in the boy-parts by a piece of his broken motorcycle, fingers cut off by power saws, and every conceivable traumatic injury in between, it seems like the Call Gods can't possibly find something I've never seen. I think that everything that could possibly happen has happened, and I've seen it. But then the Call Gods throw me a curve ball, something that even my wildest imagination couldn't envisage.
Yes, it happened again.

My second patient of the day was another fall victim. The first one had been an elderly lady who fell down the stairs and broke her back. This one, however, had fallen from a standing position. When I heard that mechanism of injury, I groaned. Audibly. LOUDLY. For patients like these, I think of it this way: if you fall from a standing position badly enough to pass out, you probably are A) drunk, B) drunk, C) drunk, or D) otherwise unhealthy enough to have passed out merely from falling down. They are usually not the worst injured patients, and I rarely get too excited at the prospect of seeing another elderly ground-level fall "victim" with bumps and bruises and little else.

His workup was essentially negative - bumps and bruises, a cervical strain (whiplash), and a concussion. So if he sounds like most of the other ground-level falls, why the hell am I writing about him?

Because he wasn't drunk. He didn't trip and fall. No, Arthur was wrestling with his wife who got the better of him, jumped on his back, and put him in a choke hold until he passed out and fell flat on his face. Five minutes later when he still hadn't awakened, his wife freaked out and called emergency services.

As he explained what had happened, his wife walked in. She couldn't possibly have been as tall as Arthur's chest, and she might have weighed 1/3 what he did. I listened to Arthur intently, my eyes flitting from him to her, trying to look him in the eye while all the time doing my best not to break out in a fit of raucous laughter.

Did he let her win, or is she some kind of human honey badger? I have no idea, but fortunately the little Tasmanian devil didn't do any major damage. As I walked out, only one thought crossed my mind:

Tuesday, 2 December 2014

Based on the title you may be worried this post will be some theistic diatribe. Nay, never fear, intrepid readers. I would never subject you to such nonsense which I would never want to read and which, I'm fairly certain, violates several portions of the Geneva Conventions. However, Mrs. Bastard has often told me that everything happens for a reason and that things may be signs from above, so while I don't have any idea what those reasons may be, I sometimes wonder if she's right.

Claudette was the passenger in a car accident early one morning. Incidentally, why is it always 1 AM? Doesn't anyone want to get into an accident and let me take care of them at 2 o'clock in the afternoon? I'm fully awake, I'm done with lunch, I have nothing better to do, so get into your accidents then! Come on! Wait, where was I? Oh right, 1 AM. Apparently her boyfriend (who was driving) fell asleep at the wheel and went off the road, hitting a tree. The tree, which was not moving at the time of the accident, didn't give one flying fuck that a car just hit it at 120 kph and remained exactly where it had been before the car hit it. Trees are kind of funny that way. Anyway, I have no idea what happened to her boyfriend, but Claudette was brought to me in a bit of a daze. She didn't have a scratch on her, but she clearly had a concussion. A CT of her brain showed a small subarachnoid haemorrhage. Fortunately she had no other injuries, and three days later she went home, sore as hell, but otherwise ok.

She followed up with me in my office about a week later. When I walked into the examination room, the first thing I noticed was the sheaf of papers from the hospital sitting on the exam table, along with her mobile phone and a cigarette lighter.

Bad move, Claudette.

If you know anything about me, you know that I look for any reason to get on people's cases for smoking, but I knew my "WHY THE FUCK DO YOU SMOKE?!" tirade would have to wait until I finished my exam and explanation about what she should expect as she recovers from her brain injury.

Wait wait wait, aren't you going way off topic here, Doc? Quitting smoking is great and all, but since when is this post about that?

Oh pipe down, you. I'm getting to it. Stop being so damned impatient.

As I was saying, after a thorough physical examination, I explained how her symptoms may last for several more weeks, but that I expected a full recovery. She told me how she couldn't bring herself to drive yet, and that she still freaked out whenever she tried to get in a car or saw headlights. She went through her long list of questions for me, and when she was finally done, I took a deep breath and gave her my best "STOP SMOKING, DUMMY!" speech. She looked rather embarrassed the entire time, but she nodded along compliantly. When I was done, she looked up with a sad little smile and said,

"You know, it's funny . . . when we got in the accident, we were on our way to the store to buy cigarettes."

. . . Aaaaaaaaaaaaaaand there it is. If that isn't a clear sign that she is supposed to stop smoking, I don't know what is.

Monday, 24 November 2014

I'd like to start this post by stating in no uncertain terms that I don't advocate people hurting themselves intentionally in any way. That being said, IF one ever decided one really wanted to hurt oneself, here are a few reasonable options one could consider:

Boisterously proclaim your hatred of the home team in any football arena in Ireland

Go 150kph on a motorcycle through rush-hour traffic with your eyes closed

Attend a New York Yankees game wearing a Boston Red Sox hat and jersey

It had been a rather boring day for me. So far I had gotten only 1) an 80-year old woman who had mistaken her accelerator for the brake pedal, crashed into a wall, and fractured her ankle, knee, and wrist, and 2) a 20-year old who had gotten hit by a bus and had a broken ankle. Since I don't do bones, I called the orthpaedic surgeon so he could work his magic on both of them, and I waited until something truly epic arrived.

My wait would be long and tragically fruitless.

Around 10 PM I got a call that my next patient would be a 15-year old boy who had been hit by a car while riding his bicycle. Fifteen years old. Ten o'clock at night. On a bicycle. I'll give that a second to sink in.

Ok, ready?

Hopefully you're all thinking the same thing I was at the time - What the hell is a 15-year old boy doing riding his bicycle at night? If you were thinking anything else, I'd like to invite you to leave now, since we're clearly not on the same page. Anyway, for those few of you still remaining, as I waited without bated breath, I had already started mentally reviewing the lecture I would surely be giving him about not being stupid. Sammy arrived a few minutes later looking entirely uninjured. It took me all of about 18.2 seconds (I timed it) to discover that his only outward sign of trauma was a small abrasion on his right ankle. About 5 minutes later I was looking at his completely normal X-ray, so I gave him the good news that all he had was a sprained ankle and opened my mouth to start the diatribe.

And then Mom got to to the hospital.

She had a look of sheer panic on her face, and I immediately realised that she had no idea what had happened and was imagining her son dead in a ditch. I put my harangue on hold and quickly ushered her in to reassure her that Sammy was fine, but that I needed to talk to them both.

Ready. Steady. GO.

"My first question for you," I asked Sammy, "is what the hell you were doing riding your bicycle at night." It wasn't so much a question as an opening statement.

Sammy looked a bit stunned, hung his head, and sheepishly turned away, clearly choosing not to respond rather than giving an answer that he too knew would be stupid. I looked at Mom who was staring intently at her son with the painfully-obvious "WHAT THE HELL DID YOU JUST DO? ANSWER THE MAN'S QUESTION!" look (Note to MomBastard: yes, I remember that look well).

But I wasn't nearly finished with him yet. Not remotely. I waited a moment until he looked back at me, and then I fixed him with a stare dead in his eye.

"I see a lot of injured patients in this trauma bay, and most of them have done something really stupid that landed them here. You just did something REALLY stupid." He looked away again.

I glanced up at Mom, expecting her to look shocked at my words, but she only nodded, silently giving her consent for me to continue. I obliged.

"Were you wearing a helmet?" He shook his head no. "THAT was stupid. Riding your bike at night? THAT was stupid. Riding your bike A) at night, B) without a helmet, and C) while wearing black sweatpants and a black shirt? THAT was REALLY stupid."

He couldn't even bring himself to look me in the eye.

"You got lucky, Sammy. This time, you got lucky. Next time you do something stupid you might not be so lucky. I do NOT want to see you back here in my trauma bay. Understood?"

He nodded, almost imperceptibly.

I turned to go and caught Mom's eye. She mouthed "Thank you" to me and started crying as I walked out without another word.

Sammy is still a young, impressionable teenager, one who still has the capacity to learn from a mistake that was indeed very stupid, though fortunately not costly. This time. Perhaps next time he won't be so lucky. But with a little reinforcement from Mom after my little tirade, maybe there won't be a next time. Maybe, just maybe, I gave Sammy something he can take with him forever.

Monday, 17 November 2014

What makes the earth spin? Forget everything you think you know about science, astronomy, gravity, the Big Bang theory, relativity, and Kim Kardashian's ass. No, what really makes the world go round is humour. The gravity (har har) of any situation can be lightened by a well-placed quip, and nothing is ever so serious that a joke can't help. Nowhere is this fact more evident than in the medical world. Hospitals are big buildings full of sick, infected people, and some of these unlucky people die every day. The mood in any hospital is typically somber at best, so anything that lightens the atmosphere can help.

Bess apparently understands this about as well as anyone I've ever met.

When a 70-ish year old woman falls for no apparent reason, everyone around her starts to worry. Was it a stroke? A heart attack? Anaemia? Something else? When Bess fell it was no different, except instead of simply crumpling to the ground, she bonked her head (yes, "bonk" is the technical term) on the corner of her kitchen counter. There was a large pool of blood on the ground when emergency services arrived to her house, and they brought her quickly to me.

On arrival Bess was completely alert, though she had neither memory of falling nor any idea why she fell. She had a small laceration on the side of her head, but no other obvious injuries. She maintained a smile throughout her initial workup, which fortunately showed no evidence of serious injury. After giving her the good news, I dutifully went to tend to another patient when I heard a clamour coming from another part of the department. We have crazed lunatics in there regularly, and the antics of someone high on PCP can instantly elevate the mood of me and my staff on an otherwise dreary night. But nothing could have prepared me for what I was about to experience.

I walked into the main treatment area and saw what I can only describe as the closest thing I've ever seen to an actual bull in a china shop: a 250-kg woman (that's around 550 lb) was lumbering through the department, poking her head into every room, with 4 nurses trying to surround her.

And she was stark raving naked.
Several security guards were trying to usher her back towards her room, but she easily outweighed them all. One of the nurses had a gown (extra large, if you're wondering) and was trying to lasso it around her neck to help her maintain some semblance of decorum. Despite all this the woman continued her tirade, giving each and every patient a bit of a show. At last the parade ended at my trauma bay . . . and Bess. The look on Bess' face when the procession entered the trauma bay was a mixture of horrifying shock and bemused merriment. The woman took one look at Bess, shook her head (I suppose Bess didn't have what she wanted), turned around, and trudged slowly back to her room, her entourage in tow. I looked at Bess, a look of terror and desperation on my face. I opened my mouth to apologise, my brain still trying to fully process what I had just witnessed. But before I was able to formulate any words, Bess, her face completely straight, said,

"That sure is a lot of beef on those hooves."

I couldn't decide if I wanted to give Bess a hug or a high five. So I decided to do both.

Monday, 10 November 2014

For all of my American readers, I'm going to clarify this at the very beginning so there is no confusion: when I say "football" I am referring to the game where you ACTUALLY USE YOUR FOOT ON THE BALL ALL THE TIME, not the game where they throw the ball or hand it to a teammate but only kick the ball a few times a game. I don't have anything against people who enjoy that flavour of football, but how the hell is that game called "football" anyway?? Who decided that "football" would be an apt moniker? It makes no goddamned sense! The only way they use their feet during that game is to run away from the behemoths who are trying to smother them like and knock them unconscious! So when I say "football", I don't mean your American football, I mean what the other 95% of the world means. Sorry, mini-rant over.

Alright, now that that bit of nastiness is out of the way . . .

Football is not usually a dangerous sport. Some of the tackles may look a bit violent, but serious injuries are fortunately rare. However, considering the commonness of the game, I get plenty of football players in my trauma bay. Most of them have collided violently with another player and thankfully suffer no more than a concussion and some bumps and bruises at worst. But I do see the odd tibia fracture from someone getting kicked in the shin (usually during a "friendly" game where shin pads aren't being worn), but they are few and far between. So recently when my pager told me I was getting another football player in 10 minutes, I figured it would be another quick workup, another minor injury, and I could get back to reading A Game of Thrones.

"I was getting to that, doc. So six weeks ago I was playing football, and I got kicked in my right thigh. It really hurt, but I played through the pain. I took some pain medicine and it got better and it's been feeling ok since, until this morning when it started hurting a bit again. But I decided to play through the pain again. Then I got kicked in the thigh again during our match today. It really hurt again, so here I am."

This seemed utterly ridiculous. He hadn't struck his head, he hadn't lost consciousness, he had no lacerations or abrasions or ANY other injuries, and was an otherwise healthy young man. Why did the medics designate him a trauma?

I had no idea, and by the time I realised I wanted to ask the medics what the fuck they were thinking, they had left. In a bit of a hurry, I would say. I had even less of an idea when I saw his completely normal femur X-ray.

"Yeah, I didn't think it was broken either, doc," he told me. "But they said it looked bad so I should get it checked out."

Fifteen minutes after he arrived, he walked out of the hospital with a prescription for ibuprofen and instructions to avoid football for a while.

I'm used to caring for people with life-threatening injuries. I take care of shattered spleens and lacerated bowels and eviscerations and gunshot wounds to the heart. These are the injuries that I typically deal with. So I should have been glad he wasn't seriously hurt. I should have been happy he didn't need surgery. But instead I was merely annoyed that the medics brought this kid to me unnecessarily and thoroughly wasted his time. And mine.

Monday, 3 November 2014

Of the many questions I've gotten, the most common is some version of "What is the hardest thing you've had to do as a surgeon?" My answer has generally been to tell some long, drawn-out, maudlin story of my most difficult and complicated surgical case. But after answering that question way too many times, I thought more about what the most appropriate answer should be, and much to my own surprise I've decided to change my response completely. In fact, the toughest thing I've ever had to do, by far, is . . .

. . . buy a gift for my wife.

Yes, shopping for Mrs. Bastard is more difficult and more nerve-wracking than removing a shattered spleen and repairing a torn colon while doing internal cardiac massage because the patient is actively bleeding to death. I tried buying clothes for my wife once. Once. That's a mistake I'll never make again. I once bought her a gift certificate to a very nice spa thinking she could enjoy a day getting pampered, but she never redeemed it. My one great success was a surprise birthday vacation to a remote tropical island, but how often can I really get away with that?

I know a few of you out there are thinking, "Just buy her jewelry, you idiot!" Wait, why didn't I think of that? Oh wait . . . I have. It's the most obvious answer, so of course I've thought of it. Unfortunately my taste in jewelry is completely different than Mrs. Bastard's. That is to say, pieces that I think are beautiful, she thinks are hideous. And pieces that she loves I wouldn't think to buy her in a million years. She almost never wears any piece of jewelry I've ever bought her (that she hadn't picked out herself in the first place).

Several months ago I was explaining to a patient exactly how I was going to remove her gall bladder - the number of incisions (3), the size of the incisons (10 mm, 5 mm, and 5 mm), where each instrument would go and what they would be doing. When I paused to ask if she had any questions, she only had one: "Can I keep the stones?" As odd as that sounds, it wasn't the first time I've been asked, not by a long shot. But it was the first time I thought to ask why.

"I'm going to make a pendent out of it and wear it."

I laughed, thinking she was kidding. She just stared at me with a perfectly straight face. A 0.195 second Google search told me that not only wasn't she kidding, but the idea wasn't even hers:

Apparently there's an actual market out there for people who want . . . this. There's really nothing more that I can really add, so I'm just going to leave that there.

But while I'm on the subject of jewelry, I was reminded of this little gem (har har har) from some time back. It's my second-favourite actual real X-ray of an actual real patient of mine. He was in a car accident at 2 AM, the details of which are entirely unimportant. Part of our workup included an X-ray of his pelvis, which didn't show any fracture. What it did show, however . . . actually, I don't want to give away the punch line. Take a look and see if you can make the diagnosis:

In case you aren't a radiologist and/or have never seen a cock ring before, that's . . . ah shit, I just gave it away. Yes, that round thing at the base of his penis in the lower middle portion of the X-ray is indeed a cock ring. So what was he doing driving around by himself while wearing that bit of jewelry at 2 AM?

It remains a very strange, exotic mystery. THAT is a question I did not ask.

But speaking of questions, I wonder what Mrs. Bastard would think of getting some gallstone earrings for her next birthday . . .

Monday, 27 October 2014

There are certain things in life that shouldn't need to be said, things that should be self-explanatory and only require common sense, things that most people with more than 17 neurons should be able to figure out on their own:

Don't touch a wall that says "Fresh Paint"

Don't touch an electric fence that says "WARNING: ELECTRIC FENCE"

Don't run with scissors

Don't throw knives at your brother

Don't drink and drive

I like to think that the term "common sense" was invented for a reason. That reason, of course, is that common sense is common. Or at least it should be. It's a very simple concept, one that boils down to three simple words that my father (DadBastard) told me on my wedding day: DON'T BE STUPID. Those three little words cover a lot of ground and will keep a lot of people out of a lot of trouble if they just bothered to remember them every now and then.

I think anyone who has lived on this planet for more than a decade can definitively tell you that common sense is in no way common.

On my initial head-to-toe assessment, it was difficult for me to get past Thom's head since there were at least 10 separate lacerations on his scalp, all of them bleeding to some degree. I fashioned a makeshift turban to staunch the bleeding, and my survey continued southward. He miraculously appeared to have no broken bones or other serious injures. A CT scan ruled out any serious brain injury, but his labwork revealed the true nature of his problem: his blood alcohol level was about 6 times the legal limit.

I went through two stapling devices (which contain 25 staples each) to get all his scalp lacerations closed. I then hydrated the hell out of him, let him sleep it off, and sent him home.

A week later Thom came back to see me to get the staples removed, and something seemed a bit off with him in the waiting room. I watched him get up and walk into my examination room, and though it was rather subtle, he seemed to be off-balance slightly. My first thought was that he actually had a serious brain injury that I had somehow missed. Not two seconds later when he approached me, my worry was allayed and my ire started rising:

Thom had shown up to his follow-up appointment drunk.

He wasn't nearly as intoxicated as he had been when we first met and he was clearly trying to hide it as best he could, but the smell on his breath was unmistakable, as were his bloodshot eyes and his slurred speech. And the bottle of whiskey in his jacket pocket.

I wish I could eliminate the term "common sense" from the lexicon since it is an obviously glaring misnomer. Unfortunately "rare sense" and "unheard-of sense" just don't have the same ring to it.

That being said, I've also gotten several requests from folks asking me to advertise or promote something. If you have never noticed the distinct lack of adverts on this blog, you will now, and there's a very good reason for that. Because of that ad-free philosophy, every shameless request for every shameless promotion I've gotten, I've politely declined.

Until now.

This one is just too important. I got an email from Sandra (her real name) from RegencyShop.com about a charity auction they are running for breast cancer awareness. Yes, October is Breast Cancer Awareness Month. Now I will happily admit I have little doubt that there are likely few people out there who aren't aware of breast cancer, but I have even less doubt that every little bit helps, especially considering how prevalent and pervasive breast cancer is. I've met very few people who don't know someone who has personally been affected by breast cancer.

One great part about this auction is that all the proceeds will go directly to breast cancer research. Wait, that's not the best part? So what is?

Monday, 13 October 2014

These are a few of the emotions that try to run through my mind as I evaluate every new trauma patient, especially the tough ones. Not every emotion rears its ugly head for every patient, but there is usually some combination of several of them. I say they "try" to get through, because in order to get through my day, I am forced to suppress every one of them and yield only to "Rational Thought". It's the only thing that allows me to do my job thoughtfully, professionally, thoroughly, and without yelling at people and going completely bonkers. I've been asked innumerable times how I'm able to separate my emotions from my actions and stay calm in the midst of turmoil and chaos, and there's one very simple answer:

I have no goddamned clue.

No really, I haven't the slightest idea. I don't meditate, I don't say any calming words to myself, I don't try to align my qi, and I don't use any other techniques (that I know of) to remain unflustered. But however I do it, you'd better be damned happy that I can, because as a trauma patient lying on a gurney and staring up at the ceiling with your intestines hanging out, the last thing you want is your trauma surgeon freaking out and losing his mind.

Several months ago, however, I experienced a case that threw my entire system into sheer turmoil and threw my qi right out of alignment. Or something.

There are three B's in the trauma arena that I just don't do: bones, burns, and babies. I let the orthopaedic surgeons do bones, I transfer any burn victims to the local burn centre, and any injured children are supposed to be taken to the local children's trauma centre. Yes, I said "supposed to", so if you're reading between the lines, you can probably see where this is going.

After a full day of mostly uninteresting patients, I was just sitting down to eat a sandwich (meatball, of course) when my pager went off. Meh, probably another elderly person who fell and bonked her head, I thought.

A "trauma in the trauma bay NOW" call usually means a family member or friend (or occasionally an ambulance) drove the patient in, and the triage nurse upgraded the patient to a trauma on arrival. When it's a "gunshot wound in the trauma bay NOW", it usually means a car drove up to the emergency entrance, pushed a gang member with several new holes in him out the car door, and sped away.

If only it were something that mundane.

I ran down to the trauma bay, and what greeted me was a crowd of approximately 195 people milling about. I pushed my way through the throng and what I saw made my mouth go dry and my heart sink: a little boy about my daughter's age with a bullet hole in his forehead.

WHAT. THE. HELL. IS. THIS, I thought to myself as I tried to force out of my head the image of one of my children lying on a gurney like this.
Despite the chaos I managed to compose myself and get the story from one of the police officers in the room. He had found the child on the ground at a local park, and instead of waiting for an ambulance, he picked the boy up, put him in his car, and drove him directly to the hospital.

I couldn't get the picture of my children out of my mind.

The little boy was still breathing and his heart was beating, but he was obviously in very bad shape. We inserted a breathing tube and took him straight to the CT scanner, where I saw exactly what I was hoping not to see: the bullet entered his forehead and went through most of the right side of his brain before stopping in his occipital lobe. His brain was already swelling dramatically, and there was almost no space left for it to go.

My son . . . my daughter . . . lying on the ground . . .

My hands were shaking.

I got on the phone immediately with the local children's trauma centre and told them the story, and they said they would send a team immediately to pick him up. As I hung up the phone and sat down, the raw emotions flooded over me like a tidal wave washing over a defenseless beach. I looked at one of my assistants who looked like she was about to cry too. Fortunately for the sake of the boy's mother (whom I had just brought into the trauma bay), both of us were able to keep our composure.

If anyone has ever wondered why I only treat adults, now you know.

The minute I got home the next morning I grabbed both of my children, hugged them, kissed them, and told them over and over again how much I love them. They both seemed very confused why Daddy wouldn't let them go, but I finally let them wriggle free after I was sure they knew. Even Mrs. Bastard started crying when I told her about it.

It takes a lot to get me riled up, but cases like these shake me to my very core and make me appreciate what (and who) I have that much more.

Monday, 6 October 2014

About nine months ago I left the sad saga of Jahi McMath behind and moved on, thinking everyone else (including her family) would do the same. Boy, was I ever wrong.

Now this is not the first time I've ever been wrong about something (just ask Mrs. Bastard), but unlike many people, I have no problem admitting when I'm wrong when I've been proven so. I see no purpose in continuing to argue even in the face of overwhelming evidence against me.

But just when I had thought I had heard the end of the story, Jahi's family (along with their lawyer Chris Dolan) came roaring back into the news this week with some rather astonishing claims, and an even more unbelievable request: based on some purported new tests, they are petitioning the court to overturn her death and declare her alive.

I'll give you all a moment to bask in the glow of that mind numbing stupidity before I move on.

One of the main reasons for this request is the contention that Jahi is responding to and following commands. Two videos were released that appear to show just that:

Before anyone rushes to judgment ("It's a hoax! It's a fake! There are strings attached!"), I am reserving judgment on these videos myself. It is possible that she was moving her hand and foot before the camera started rolling (which, by the way, is an obsolete phrase. Cameras don't roll anymore. Non sequitur over.), and that Jahi's family took advantage of her pre-existing spinal reflex movements and recorded them. And before anyone asks, studies show that these type of movements in brain dead patients are not that unusual, occuring in about 1 in 7 brain dead patients. From the article:

The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet.

In case you didn't (or couldn't) watch the videos, these are exactly the movements that Jahi is making.

If that weren't enough, there are other claims made by the family and their lawyer. Apparently she has started menstruating, and Dr. Alan Shewmon, a well-renowned and rather famously anti-brain-death neurologist, claims this proves that she is not brain dead, since the pituitary gland is responsible for secreting the hormones that are responsible for menses. Game, set, and match. Right?

Ah ah ah, not so fast. Studies on brain dead women have revealed that function in both the hypothalamus and the anterior pituitary gland (the portion that produces FSH and LH), is preserved even in brain death. So the fact that Jahi now has her period is interesting, but meaningless.

The family's next assertion to support the "Jahi is alive" line is that an MRI shows preserved brain tissue. Here is a screenshot of her MRI:
If there are any radiologists looking at this, a comment would be gratefully appreciated. What this shows is catastrophic damage to her midbrain and brain stem, but it does show some preserved cerebral cortex (brain tissue). What this means functionally is impossible to assess based on this one image. This alone doesn't mean she is alive. All I can really say is that there is some brain tissue there. Again, interesting but meaningless.

Perhaps the most astonishing claim is that she has electrical activity in her brain based on a recent EEG. I haven't seen her EEG, but this is enough to make me stop and think. Brain death means a silent brain, so there should be no electrical activity in there at all. If she does have electrical activity, that raises a lot of question marks.

The most telling part of this news is that the doctors supporting these claims hail from the International Brain Research Foundation which is based in the United States. I sure was impressed that such an impressive-sounding foundation would support the idea that Jahi could come back from brain death . . . until I looked into the IBRF and discovered that they are a collection of alternative therapy-driven self-described "mavericks" of brain injury research. To give you an idea of who these people are, their chief medical officer Dr. Jonathan Fellus lost his medical licence this year for having sexual relations with one of his brain-injured patients. It's unethical enough having an extra-marital affair with a patient, but doing it with a brain-injured patient is simply unconscionable (pun intended). If you really want to be creeped out, read the full article.

Not all the doctors who are looking at Jahi are like ex-Dr. Fellus, however. Dr. Calixto Machado, a well-respected Cuban neurologist and author of numerous articles on brain death (including one I have referenced myself), has been asked to evaluate her. Dr. Charles Prestigiacomo, chair of neurosurgery at Rutgers University, has also raised questions based on the results of the various studies (though I'm not sure if either Dr. Machado or Dr. Prestigiacomo has actually examined her).

Damn, this ended up much longer than I was expecting.

Anyway, the bottom line here is that no objective evidence that Jahi McMath is alive has been presented. There must be independent confirmation of the family's claims by a competent doctor. If the claims are verified, then one of the following two statements must be true:

All six doctors who examined her back in December and declared her brain dead were wrong, they all interpreted her brain death studies incorrectly, and all of the studies showing she was brain dead were wrong, or

Brain death is not absolute and it is possible to recover, even somewhat.

If the claims are verified, then she is most certainly not dead, and every medical textbook publisher on the planet will have to revise every medical textbook on the subject of brain death. If that time comes, I will readily and freely admit that I was wrong, and every other doctor that believes that brain death equals death and is finite and irreversible will have to do the same.

But if the claims are untrue and/or this turns out to be nothing more than a cruel hoax, then shame on the family, shame on the lawyer, shame on the IBRF, and shame on the media for drawing out this incredibly tragic affair even longer.

Wednesday, 1 October 2014

WARNING #1: I MAY SOUND LIKE A CALLOUS ASSHOLE IN THIS POSTWARNING #2: I'M NOT TRYING TO SOUND LIKE A CALLOUS ASSHOLEWARNING #3: I DON'T GIVE A FUCK IF I SOUND LIKE A CALLOUS ASSHOLE
I wear two hats on a daily basis. Under the first hat is a general surgeon who is trying to save the world from appendiceal disease one goddamned appendix at a time at 2 AM (always at 2 AM). I'm also trying to cure the world of breast cancer, gall bladder disease, colon cancer, chronic wounds, skin cancer, hernias, and a host of other problems, some big and some small. But under the trauma surgeon hat, I'm mainly dealing with stupidity. And as comedian Ron White said, "You can't fix stupid".

As a trauma surgeon, all I deal with are injured people. After practicing trauma surgery for {redacted} years, I have a very good sense for how long people should be in pain, how long people should be in hospital, and who should be able to go straight home to finish recovering versus going to a rehabilitation facility. Most people are anxious to get out of the hospital and get back to their normal lives. Some tragically misinformed people think spending extra time in hospital will make them better. A few people try and take advantage of my good will by trying to wheedle extra time off work.

Superficially, Stuart was little different than many of the other motorcycle victims I've seen over the years. He was a large fellow in his mid-20s, covered with tattoos, and he fell off his bike when he took a turn too fast and hit a patch of gravel. He tumbled over and over, narrowly avoiding getting run over by the car behind him. When he arrived at my trauma bay, he was clearly in discomfort, mainly in his lower back, left chest, and right thigh. A quick look at his right thigh told me something bad was going on - it was swollen and deformed, a sure sign that his femur was broken. When I touched his chest he yelped, so I immediately thought of rib fractures. An X-ray confirmed a simple fracture of his femur, and a CT of his torso showed a pneumothorax (collapsed lung) on the left but no broken ribs. He did have three minor fractures in his lower back, but they were clinically insignificant, the type of fracture that is annoying but doesn't cause any disability.

About 18 hours, one chest tube insertion, and one femur repair later, I entered his room on my morning rounds, and Stuart barely opened his eyes to greet me. "How are you?" I asked in my cheeriest voice (as cheery as I can be at 7 AM before my first cup of coffee).

"Terrible," he droned. I didn't expect him to be nearly as cheerful as I was less than 24 hours after his accident, but I would have at least appreciated him making an attempt to open his eyes and acknowledge my presence. Typically pain starts to improve dramatically the day after surgery, so the next morning I figured he would be a bit peppier.

Day 3: "Terrible," he moaned, again without even bothering to look at me. After discovering that he hadn't even tried to work with the physical therapist the day before, I nicely explained that today was the day for him to get out of bed and start working on his recovery. I also gave him some good news - I would be removing his chest tube that morning, so hopefully that would help alleviate his pain and encourage him to get out of bed. I expected to be able to send him home later that day, or the next morning at the latest.

Day 4: "Terrible," he groaned. He barely opened his eyes before telling me that he didn't bother trying to get up the day before. Again. "Ok, I know you're in pain, but let's work on getting that under control and getting you up and walking today so I can get you home," is what came out of my mouth while GET UPis what was going through my mind.

Day 5: "Terrible," he whined. He still hadn't even made an attempt to get out of bed despite my encouragement. His nurse the day before had also tried encouraging him, giving him a bit of tough love that he obviously needed. She tried to get him to be an active participant in his recovery. His response was to demand a different nurse, a request that I flatly refused. GET UP!!

Day 6: "Terrible," he whimpered. Somehow he had still avoided getting up out of bed. I tried explaining how bedrest doesn't make you better.Quite the opposite - the longer you stay in bed, the weaker you get. He just turned over in bed. GET YOUR ASS UP!

Day 7: "Terrible," he cried. The therapists, with the assistance of 4 nurses and aides, had finally managed to get him up into a chair. It had also been the first day he had even allowed the nurses to change his bedsheets since his admission. Despite our encouragement, he continued to actively prevent his own recovery. GET YOUR LAZY ASS OUT OF THIS FUCKING BED, YOU GODDAMNED SLUG!

I won't bore you with days 8-10, because they were eerily similar to 1-7. His array of injuries should have resulted in a 3-4 day hospital stay and him walking out of the hospital. Instead, he stayed for well over a week and ended up going to a rehabilitation facility to finish recovering, all because he refused to participate in his own care.

If you're ever unfortunate enough to be a patient of mine or one of my colleagues, keep one very important thing in mind: the biggest advocate you have for your own health is you.

Tuesday, 23 September 2014

Most of the patients I see aren't injured severely enough to warrant time off from work and are able to go immediately back. Some I estimate will need a few days off, some need a week or two, and a few likely even need several months to recuperate. I don't mind writing excuse letters for those with severe injuries, and I'm typically rather lenient with granting time off to recover, partially because I feel bad for them, but mainly because I don't feel like arguing with people (I realise that may come as a surprise to you).

As usual, step 1 is to inspect the wounds. I quickly unwrapped his hand and thigh and then paused, staring agape at what confronted me.

"How bad is it, Doc? Tell me straight. Am I going to live?"

The 2 cm laceration on his outer thigh and the 1 cm laceration on his ring finger, neither of which was bleeding, did not make me fear for his life.

"Yes, sir," I said flatly, doing my best not to slap the shit out of him for his histrionics. "I suspect you're going to be just fine. May I ask what happened here?

It turns out that Kevin carried a pocket knife but had forgotten to close the blade before putting it back in his pocket. He then sat on the blade, lacerating his thigh, and when he reached into his pocket to retrieve the knife, he cut his finger.

Twenty minutes and 5 stitches later, we were writing up his discharge papers. And that's when he hit me with this:

"So how much time off work am I gonna get for this? I think I'll probably need a week. Maybe two. Yeah, I think two."

I explained in no uncertain terms that he could go back to work the next day.

Thursday, 18 September 2014

I may glamorise my job from time to time (read: all the time) to make myself and what I do seem more interesting. The sad reality (from my own skewed point of view) is that the majority of my patients are only mildly injured (and sometimes not injured at all). Most patients get worked up in A&E/ER/ED/casualty department and sent home the same day with stitches, staples, splints, bandages, and/or a stern lecture from me about how to prevent this sort of thing, whatever it may be, from happening again. For me repeat customers, though good for the bottom line, are bad for business. If that makes any sense at all.But who the hell wants to read about someone who was in a minor car accident but was brought to me just as a precaution? Who wants to know about the old lady who loses her balance and bonks her head on an end table and ends up with nothing but a bump on the head and a mild concussion? Who cares about yet another drunk guy who falls off his bar stool, spends a couple of hours with me sobering up, and then endures a real sobering drive home with his wife appropriately yelling at him from the driver's seat? Is anyone even remotely interested in any of that?I'm certainly not, but I have no choice in the matter. But I spare you good people the details about the mundane and boring people who come in with minor injuries, mainly because if I didn't you would all run away faster than teens from a Wiggles concert. No? Ok, faster than men from a Taylor Swift concert. Still no? Ok, faster than sane people from a Miley Cyrus concert. Yes. Perfect.Anyway, this next guy is not one of those boring people.

When Orville got to me, he wasn't moving at all and was obviously close to death: his heart was beating around 160 times per minute because it was trying to compensate for his dangerously low blood pressure. About 60 seconds later, his heart gave up and stopped.

With CPR, several units of blood, and some medications, we restarted his heart a few minutes later, and we continued transfusing even more blood as we were finally able to start our evaluation. The first and most obvious thing I noticed is that his head looked completely uninjured, unusual for someone in such a severe accident.

"He is a complete mess," I mentioned to one of the assistants. "But at least his head looks ok. But that's about the only thing that looks ok."

It always amazes me when I hear idiots claim that getting thrown from a car is safer than staying in it. Would you rather get thrown out of a car and deal with all the kinetic energy of hitting the ground, or would you rather stay in the car where all the seat belts, airbags, roll cages, and crumple zones surrounding you and keeping you safe are?

Saturday, 13 September 2014

At the risk of sound redundantly repetitive, superfluously repetitious, and recurrently mundane, I believe very firmly in the Call Gods. I know I bring them up a lot, but despite the fact that Mrs. Bastard and I take the Call Gods very seriously, I get the feeling that a lot of my readers don't.

That is a seriously bad move.

I remain deathly afraid of the Call Gods (even more afraid than I am of huntsman spiders), but only because they continue to demonstrate that they are real. Really real. And really evil.

A colleague of mine presented our monthly trauma conference recently. He spoke of a young man who had been involved in a high-speed rollover motor vehicle accident and was obviously in shock when he arrived at our hospital. My colleague's workup demonstrated a large laceration of the right diaphragm (the muscle that controls breathing, separates the chest from the abdomen, and keeps all the guts in the belly). The laceration was so large that his entire liver was up in his chest, compressing his lung and preventing him from breathing properly. My colleague took him to surgery, pulled his liver back down into the abdomen where it belonged, and repaired the diaphragm. It was an excellent presentation with a great outcome for the patient, and I listened with a mixture of curiosity and fascination.

Now I've seen innumerable knives and bullets poke holes in the diaphragm that I've subsequently repaired, but those are always relatively small injuries (either knife- or bullet-sized) that are fairly easily fixed with a stitch or two. But blunt diaphragmatic injuries like the one my colleague presented are typically much larger (and rarer) and can be very difficult to diagnose and repair. All during the presentation I kept thinking to myself, "With all the blunt trauma I see, I can't believe I've never seen a blunt traumatic diaphragm injury."

See where this is going yet? Talking about the Call Gods . . . Yeah, I didn't at the time.

I happened to be on call that same day, and it turned out to be a very light day with only two low-level, minimally-injured fall victims coming in. So after finishing up writing a blog post, I thought I might tempt the Call Gods and lie down to try to get some sleep that night.

HA! No. The Call Gods were watching me carefully, and they obviously decided they would not be allowing anything like that. Not during their watch.

Just before midnight my lovely pager (which I adore and never want to throw across the room) informed me that a level 1 (high level) motor vehicle crash victim would be arriving in 5 minutes. Two minutes later as I rushed towards the trauma bay, my lovely pager nearly did get thrown against the wall when it told me a second high-level car accident victim would be coming in another five minutes.

Triage mode: activate.
Victim #1, a young man in his 20's who had been driving way too fast (without his seatbelt on, naturally) and had struck a tree, arrived moaning about 4 minutes later, his heart pounding away at 140 beats per minute. His blood pressure was ok, but his oxygen level was low. A quick push on his chest revealed air in the soft tissues and a distinctively sickening crunchy feeling, a sure sign that he had rib fractures which had punctured his lung. We had just enough time to insert a chest tube to re-expand his lung before victim #2 (who happened to be victim #1's passenger) arrived. He was also in his mid-20's, but he looked much closer to death than his friend. His heart rate was around 160, but his blood pressure was so low it was nearly undetectable. His pelvis was obviously severely fractured and was likely bleeding profusely internally, so we put on a pelvic binder and started transfusing him rapidly with blood. As his blood pressure improved, victim #1 went over to the CT scanner, and as it scanned through his chest the first thing I noticed was his stomach and spleen in his chest.

Very funny, Call Gods. Very fucking funny. Assholes.
In case you don't remember your basic human anatomy, the stomach and spleen belong in the abdomen, not in the chest. This guy obviously had a ruptured diaphragm, a diagnosis I confirmed in the operating theatre a few minutes later. As expected I found his entire stomach, his lacerated spleen, and portions of his colon and small intestine protruding through a gaping hole in his diaphragm. I pulled all that stuff out of his chest, fixed the 14cm hole in his diaphragm (yes, that's big), removed his bleeding spleen, and fixed two lacerations in his colon.

I'd like to say that he walked out of the hospital a few days later, but his shattered hip somehow prevented that. He also had several other potentially-lethal injuries, including a transection of his aorta, which as you can imagine is bad. Not just bad, but VERYBAD. It's a particularly nasty injury where the aorta ruptures just past the point where it turns south towards the feet. Nearly 90% of patients with this injury die before reaching the hospital, and overall 95% don't make it. Yet he did.

His friend survived too, even though his list of injuries was far longer. I'll address him in a future post when I fulminate again about seatbelts.

If I ever had any doubt about the Call Gods' existence (not that I ever really did, mind you), this eliminated any shred of uncertainty. {Redacted} years of practice with not-a-single blunt diaphragm injury until the day I happened to see a presentation on the subject and mention that I had not yet had one . . . it isn't just a coincidence. It can't be.

Hey Call Gods, I've just noticed that I've never won the lottery. Not even once! Call Gods? Hello?

Monday, 8 September 2014

It's that time again, folks! That's right, time for another story about my favourite idiot -

ME!

Everyone knows the unwritten rule about pregnant women. I don't mean "Don't touch the pregnant belly" because it seems everyone breaks that rule (as odd as that is). Seriously, why do random strangers feel it is their right to approach a pregnant woman they don't know and pat her abdomen? How did that ever become socially acceptable??

No, the rule I'm talking about is "Unless you are 100000% positive she is pregnant, don't ask a woman about her pregnancy. Ever. EVER. EVER EVER EVER."

I hear the gears in your collective brains turning, and you're already putting 2 and 2 together. A story about an idiot . . . Doc is the idiot . . . asking a woman about pregnancy . . .

Hahaha, no I did not break that rule! Please, I'm not that stupid.

No, I'm far stupider.

One of our trauma nurses was pregnant recently with her first child. She only works part time, so I don't see her that often. After an absense she returned, her belly still somewhat large. I couldn't remember when she was due, so I thought I would ask.

"So Tina (not your real name), when are you due?"

As I listened helplessly to the words tumbling out of my mouth, it dawned on me that the last time I saw her had been about 4 months ago, and that she had been about 6 months along in her pregnancy.

Hopefully you're not really bad at arithmetic or somehow missed that health class where you learn that human gestation is only 9 months (well, 40 weeks actually). In case you don't see the problem, Tina spelled it out for me.

"Uh, I had my daughter a month ago. Today is my first day back."

A dead, awkward silence then ensued for what seemed like an hour. During that 2 seconds of real time (but what seemed like an hour of Stupid Time) of excruciation, she looked directly in my eyes, and I swear I could actually hear her silently screaming at me, "I JUST HAVEN'T BEEN ABLE TO TAKE OFF THE BABY WEIGHT, ASSHOLE. BUT THANKS SO MUCH FOR FUCKING POINTING IT OUT ON MY FIRST DAY BACK, YOU GIANT SHITHEAD!!"

I realised immediately that there's just no recovery from that gaffe, and I may as well have slapped her in the face and called her a whore, because that would have been somehow less insulting. So I said the only thing I could have done -

"Haha! I know that. I'm just kidding. Have any pictures?"

I'm 99.99953% sure that she didn't buy it, but only because you'd have to have the brain power as low as a homeopath (sorry, I had to throw that in) to believe such a ridiculous excuse. But pull out the baby pictures she did, and after we cooed together over her 25th or so photo, all seemed forgotten.

It was another close call. I'm not sure how many more of those I'm going to get before my brain goes too far and gets me into real trouble.

About Me

I am a trauma and general surgeon at two hospitals in the suburbs of a major metropolitan area. One of the hospitals is in a rather poor suburb, the other is in a very affluent suburb. I see all kinds of crazy shit at both.
Feel free to email me at docbastard1@gmail.com if you have questions, comments, or stories you want me to publish. Yes, I'll give you credit.
Don't be afraid to comment or email me. I appreciate both!